Chapter 235
Episode 235 Abdominal Pain (2)
“This is the patient here.”
Yang Siwoo hesitantly held out a Tablet PC, its screen displaying a new patient's chart. I typed the registration number into the EMR search bar. The moment I hit enter, the patient's initial triage Printout Sheet packed the Monitor screen.
“A 38-year-old male. Chief complaint is abdominal pain. Routine Labs are out... but why?”
As I asked while scrolling down, Yang Siwoo Started his briefing.
“For now, on physical examination, rebound tenderness or rigidity isn't overtly felt.”
It meant there were no signs of peritoneal irritation, the most fundamental aspect of differentiating abdominal pain patients.
“Yeah. If no pulsatile mass is felt, it might not be a super-emergency like an aortic aneurysm rupture. Is there something Weighing on your conscience?”
At my Words, Yang Siwoo fiddled with the Tablet PC and continued. His knowledge might still be shallow, but the ominous gut feeling one gets when first facing a Patient is something you can never ignore.
“He keeps saying it’s Just a throbbing, piercing pain. But he’s also breaking out in a sweat, and he says it’s been going on for 11 hours. It started hurting last night, so he took some gastrointestinal medicine, slept for a bit, and woke up.”
“Pain scale?”
“Around a 4 on the NRS scale.”
“Hm…”
I scratched my Head while looking at the Monitor. Ambiguous. Extremely ambiguous. An NRS 4 meant daily life was a bit uncomfortable and distracting, but it wasn't the level of Pain that would have someone rolling around on the Emergency Room Floor and letting out a Scream. If an appendix had burst or a gallbladder had suppurated, they would have been rushed here in an Ambulance long ago. The fact that he could endure it for 11 hours, sleep, and wake up Seemed far removed from an ultra-emergency surgical Disease.
“I wasn't sure if this met the indications for a CT scan... so I wanted to ask.”
If you recklessly order a multi-hundred-dollar abdominal contrast CT just for a little belly ache, the Health Insurance Review and Assessment Service will often cut the Hospital's reimbursement later, calling it over-treatment without clear evidence. Then, that arrow flies straight back to the attending Doctor who wrote the prescription. For a 1st-year resident, it was a very Realistic reason to feel intimidated about pressing that examination Button.
“No contrast allergy or Kidney problems, right?”
“Ah, yes, no such history. Oh, he does have DM, but it's being controlled with medication.”
'Diabetes.'
With just that one word, my Mind Seemed to snap awake.
“Then let's order an abdominal contrast CT.”
“Ah... okay.”
I pushed my Chair back and stood up from my Spot. Comprehending a Patient solely through a Monitor is merely half-baked medicine. Even if a 1st-year resident did the interview, I can only rest easy once I Check it with my own Eyes.
The Patient was lying on the Bed. Cold Sweat was beaded and glistening on his Forehead and the back of his Neck, but his Face didn't look like he was gasping for Breath or writhing in agonizing Pain.
“Patient, I'm a Doctor.”
As I approached and spoke gently, the Patient lifted his Eyelid and looked at me me.
“Ah, yes. Teacher…”
There Was no strength in his Voice, but his Consciousness was clear. I glanced over the Patient's Abdomen with my Eyes and asked, “When did this abdominal pain start?”
“Was it from around 1 a.m. Dawn? I think that's when it hurt. I thought what I ate for dinner gave me indigestion... so I just took some gastrointestinal medicine from the convenience store and went to sleep, but…”
“How did you feel after taking the medicine? You weren't Vomiting or having diarrhea, right?”
“Yes... it just keeps throbbing and piercing. My epigastric area feels tight too, and my whole Abdomen hurts like it's subtly knotted up. The right Side, and the lower area seems to hurt a bit more.”
Listening to the Patient's answer, I carefully observed the State of his Skin. Cold Sweat. A sign that the sympathetic nervous system was excessively hyperactive for it to be just indigestion. It meant that even if the pain score was low, a stressful Situation was definitely unfolding inside the Body.
“Do you keep breaking out in a Cold Sweat like this?”
When I asked, the Patient nodded weakly. I turned my Head and asked the Nurse in charge, who happened to be re-measuring the Patient's Blood pressure and temperature.
“Nurse Jin, this person's fever, by any chance...”
“I just checked, and it's 37.3.”
37.3 degrees. Not a high Fever, but an ambiguous mild fever that wasn't a perfectly normal temperature either. It could be the earliest Alarm signaling that a microscopic inflammatory response had Started somewhere in our Body.
No tenderness. Tolerable pain intensity. However, a dull pain and Cold Sweat that had persisted for 11 hours. And diabetes as an underlying condition.
“Your Abdomen doesn't hurt severely, but since you keep sweating and have a slight fever, we need to check. It could be the early stages of appendicitis, or inflammation could be hidden in the Intestine, and we can't tell just by pressing on the belly with our hands. For now, let's take a CT scan. Please wait just a bit while receiving IV fluid.”
I reassured the Patient and left the Bed. Swish—just as I turned back to the Station to place the CT order, Yang Siwoo spoke up cautiously.
“Teacher.”
“Yeah?”
“But is this really the right indication for a CT...?”
“Was there any Vomiting?”
“Pardon? Ah, Vomiting…”
“I'm asking if there was nausea, Vomiting, or diarrhea. If it's enteritis or indigestion, it's normal for gastrointestinal symptoms to be accompanied, right?”
At my interrogation, Yang Siwoo frantically read through the initial Printout Sheet with his Eyes.
“Ah... I think he said there wasn't anything in particular. He didn't complain of nausea or diarrhea symptoms.”
“Where is the pain located?”
“The right lower quadrant.”
The right lower quadrant. A very dangerous Position where the appendix is located. I took my Eyes off the Monitor screen and looked into Yang Siwoo's two Eyes.
“Alright, then let's Organize this again. Right lower quadrant pain, but tenderness is negative. The Obturator sign, which should hurt when the Leg is flexed and rotated, is also negative. Even Rovsing’s sign, where the right side should hurt when the left abdomen is pressed, is entirely negative. If that's the case, what should we view this as?”
It meant that the most basic physical examination signs used to diagnose appendicitis had all turned up negative. Strictly according to the Textbook, it absolutely shouldn't be appendicitis. Under my Pressure-filled questioning, Yang Siwoo's pupils shook like Crazy.
“Uh, then... since there's no rebound tenderness and no signs... simple enteritis? Or maybe Muscle Pain...?”
“Wrong.”
I ruthlessly cut off the incorrect answer.
“First is the location. The place he said has been subtly throbbing since a moment ago is precisely the right lower quadrant. Second is the history of DM.”
“DM? Diabetes and abdominal pain…”
In the Head of a 1st-year resident whose clinical experience was still meager, the link between diabetes and appendicitis didn't seem to form easily.
“Diabetic neuropathy!”
“Ah...!”
Only then did a Sigh escape Yang Siwoo's Mouth. Diabetes. Patients who have suffered from diabetes for a long Time cannot feel pain properly because their nerves are damaged.
“Even if it's a State where a normal person would have already ridden in a 119 Ambulance, a patient with diabetes has dulled nerves, so they might just endure it for 11 hours. Because their inflammatory response is also lower than a normal person's, the signs of peritoneal irritation appearing on the outside manifest weakly too.”
I tapped the keyboard to bring up the Patient's Blood Lab window.
“So, just because this Patient says his belly doesn't hurt that much, or because you're scared of a reimbursement cut, you can't just hand him enteritis medicine and send him home.”
“Ah... Sorry. I failed to think that far…”
“Creatinine is 0.9. The Kidney won't be ruined even if we use contrast, so place the abdominal contrast CT order right away. Quickly.”
After checking the Kidney numbers like that, I issued the CT prescription without delay.
Before long, the abdominal CT Image appeared on the Monitor. As I scrolled the Mouse wheel to enlarge the cross-section of the right lower quadrant, an abnormally swollen, small, round tube-like structure came clearly into view amid the black-and-white Image.
“Do you see the appendix dilation? The diameter easily exceeds 1cm.”
“I see it, Teacher.”
Yang Siwoo moved closer to the screen.
“You also see the white, clumped Fat stranding around it, right? This means the inflammation has gone beyond the appendix and spread to the surrounding fat tissue now.”
“Yes, Teacher. I see it clearly.”
The Patient did indeed have appendicitis. Moreover, it was in a precarious State, quite advanced and on the verge of bursting right now.
“What do you have to do in this case?”
When I asked with my arms crossed, Yang Siwoo began to bumble once again.
“Uh... then it's not enteritis, no, it's inflammation, but since it's appendicitis... we give painkillers, contact general surgery, and...”
He had the knowledge in his Head, but he was the typical 1st-year resident who lacked training in spitting it out as a quick and accurate order in the Clinical practice field. I let out a short Sigh and recited the prescription orders for him.
“Shoot 50mg of Tramadol intravenously to control the pain, hang 2g of Ceftriaxone with 500mg of Metronidazole to load broad-spectrum antibiotics, keep him NPO, and Call the surgery resident on duty to secure an Operating Room. Is that hard?”
“Ah, I will correct this! I'll place the order right away!”
Thoroughly frozen, Yang Siwoo frantically tried to input the medication dosages I had called out.
“Forget it. I already entered it. Everyone learns and grows like this during their 1st Year.”
At my reply, Yang Siwoo finally let out a Sigh of relief.
“Ah, yes, thank you! Then I will Call general surgery right away.”
“And I'd really like you to remember this one thing.”
At my serious Voice, Yang Siwoo stood at rigid attention.
“Yes. I am listening.”
Looking at the tightly swollen appendix of the Patient on the Monitor, I threw out a famous quote from a medical drama and an unwritten rule that Emergency Room doctors must engrave in their hearts for life.
“Everybody Lies.”
“Pardon?”
“They lie. I don't mean the patient is intentionally planning to deceive you. The patient's memory might be distorted, or like Today, the sensory organs of the Body might be tricking the brain because of an underlying condition. So don't blindly trust only the subjective symptoms coming out of a patient's mouth. Bite down and cling to the objective signs and past history until the end, and doubt.”
“Ah…”
I could see the 1st-year resident's Eyes growing a little brighter.
“Alright. Go. Quickly submit the admission form to surgery.”
“Yes! Understood!”
Yang Siwoo answered energetically, picked up the Handset, and ran toward the corner of the Hallway.
It was just when I was clicking the keyboard to wrap up the appendicitis patient's prescription and trying to check the next patient list.
Swish—
Someone slammed their two arms right onto the Station table, blocking my field of vision. When I raised my Head, Lee Minjae, standing on the opposite side, was looking down at me with an incredibly obnoxious and meaningful Expression.
'There he goes again.'
I knitted my brows tightly and Leaned my body against the backrest of the Chair.
“What is it, Doctor—no, Professor. What are you doing instead of seeing patients?”
Despite my blunt reaction, Lee Minjae called me, completely unfazed.
“Hyunjae.”
“Yes, Professor.”
Lee Minjae glanced around, then leaned his upper body deep toward me and whispered secretly.
“You know Suyeon, right?”
“Do you mean Jo Suyeon?”
Jo Suyeon. A 4th-year classmate.
“Yeah, her. Hide it well from her, specifically.”
“Yes? Hide what?”
When I made an Expression indicating I Don't know what he meant at all, Lee Minjae clicked his tongue and pointed a finger at my Face.
“Your dating, you punk. Suyeon broke up last week. Even though I know you recommended EM and brought her here, how do you think her Mental state will be if a fellow classmate is radiating a pink aura right next to her while she's experiencing the agonizing pain of a breakup? Anyway... I hope you hide it well.”
What on earth is this Human talking about?
“Pardon? Hide it? Professor, how do you…”
When I questioned back in horror, Lee Minjae snorted.
“You're being way too obvious right now.”
“Gasp.”
I reflexively fumbled around my Mouth.
“You stare into the Void and smirk by yourself while charting, and whenever Baek Eunseo passes by, your pupils automatically chase after that direction.”
At Lee Minjae's words, I Was lost for words. I prided myself on hiding it perfectly, but it seemed I couldn't escape the hawk eyes of the rookie Professor. Then again, even a moment ago, I was exchanging winks with Baek Eunseo, then felt guilty by myself and put on a whole show pretending to manage my facial expressions.
“Sigh... Understood. I will be careful.”
When I bowed my Head, Lee Minjae patted my Shoulder and laughed.
“Yeah, don't get caught. Oh, and earlier in Area B, Bed number 3…”
It was during the time we were discussing minor details about the direction of patient treatment like that.
Ring-ring-ring-ring—
Ring-ring-ring-ring—
The telephone located on one side of the Station rang.
“Yes, this is the Cheongjin University Hospital Emergency Room.”
The charge Nurse guarding the Station hurriedly picked up the Handset. Flip-flopping through charts busily while talking with Lee Minjae, I was just letting it go in one ear and out the other, thinking it was just a routine admission inquiry.
However, after the Face of the Nurse holding the Handset turned cold in an Instant, we had no choice but to focus our attention.
“A gunshot wound?”
“…”
With that One word, the conversation between Lee Minjae and me snapped shut. Lee Minjae and I snapped our heads toward the telephone almost at the same time.
“What?”